Hindawi Publishing Corporation
Radiology Research and Practice
Volume 2011, Article ID 460890, 3 pages
1Radiology Residency Program, University of British Columbia, Vancouver, BC, Canada V6T 1Z4
2Radiology Residency Program, Dalhousie University, Halifax, NS, Canada B3H 4R2
Correspondence should be addressed to C. Behrens, carola email@example.com
Received 7 November 2010; Accepted 31 January 2011
Academic Editor: Sotirios Bisdas
Copyright © 2011 C. Behrens and P. P. W. Yen. This is an open access article distributed under the Creative CommonsAttribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
An inlet patch is a congenital anomaly consisting of ectopic gastric mucosa at or just distal to the upper esophageal sphincter.
Most inlet patches are largely asymptomatic, but in problematic cases complications related to acid secretion such as esophagitis,
ulcer, web and stricture may occur. The diagnosis of inlet patch is strongly suggested on barium swallow where the most common
pattern consists of two small indentations on the wall of the esophagus. The diagnosis of inlet patch is confirmed via endoscopy
with biopsy. At endoscopy, the lesion appears salmon-colouredand velvety and is easily distinguished from the normal grey-white
squamous epithelium of the esophagus. The prominent margins correlate with the radiological findings of indentations and rim-
like shadows on barium swallow. Histopathology provides the definitive diagnosis by demonstrating gastric mucosa adjacent to
normal esophageal mucosa. No treatment is required for asymptomatic inlet patches. Symptomatic cases are treated with proton
pump inhibitors to relieve symptoms related to acid secretion. Strictures and webs are treated with serial dilatation and should be
biopsied to rule out malignancy.
A 65-year-old male was referred to radiology for a barium
meal study with complaints of high dysphagia for solids with
electrocardiogram examinations were normal. The barium
study was performed with rapid sequence filming of the
pharynx during swallowing at 6 frames per second in an-
teroposterior (AP) and lateral projections. Because of the
characteristic radiological findings, endoscopy was arranged
the following day to confirm the diagnosis.
Esophageal inlet patch (also called cervical inlet patch,
ectopic or heterotopic gastric mucosa of the upper esopha-
The barium swallow in the AP view taken at full cervical
distension demonstrated two indentations in the barium
column on the right (Figure 1, arrows) above the thoracic
inlet. In between these indentations the barium column is
bulgingslightlyoutwards.These findingsarecharacteristic of
an esophageal inlet patch [1, 2]. On the lateral view, there is
slight narrowing of the barium column at the thoracic inlet
(Figure 2, arrow). The narrowing represents an esophageal
stricture that is likely secondary to acid secretion by the inlet
patch and is contributing to the patient’s dysphagia.
Ectopic gastric mucosa can occur anywhere along the
gastrointestinal (GI) tract. When it occurs in the upper
esophagus, it is called “inlet patch” because of its location
at or just distal to the upper esophageal sphincter. The inlet
patch is considered a congenital anomaly found in 10%
of the population with careful searching at endoscopy 
but it is often overlooked by endoscopists and radiologists
and studies frequently report a prevalence between 0.1
and 3% [1, 4–6]. Inlet patches are believed to be due
to incomplete transformation from columnar to squamous
2 Radiology Research and Practice
Figure 1: AP view of barium swallow showing two indentations
(arrows) above the thoracic inlet and a slight lateral bulge of the
esophageal lumen between the indentations.
epithelium during embryonic development . Squamous
transformation starts in the mid-esophagus and extends
bidirectionally and incomplete terminal transformation at
theproximal esophagusaccountsforthepostcricoid location
longitudinally, affecting only part of the circumference, but
some are annular and multiple lesions are not uncommon
[1, 3, 5].
Most inlet patches are largely asymptomatic, but in
problematic cases complications related to acid secretion
such as esophagitis, ulcer, web, and stricture may produce
symptoms such as chest and throat pain, dysphagia, globus
sensation, and shortness of breath [6–8]. The size of the
of increased acid secretion . In some cases of inlet patch
ulcer, serious and life-threatening sequelae such as hemor-
rhage, perforation, and tracheoesophageal fistula may occur
. Amongst those with concurrent inlet patch and gastric
H.pylori,73%will haveaninfectedinletpatchwhich may
exacerbate complications and related symptoms. Chronic
cough and hoarseness have been reported in association
with inlet patches, presumably due to acid irritation of
the airways and vocal cords [6, 10]. Adenocarcinoma may
arise in the ectopic gastric mucosa but this is rare and is
considered sporadic. In contrast to Barrett’s esophagus there
is no increased risk for adenocarcinoma associated with inlet
patches as they are not metaplastic .
The diagnosis of inlet patch is strongly suggested by
characteristic findings on barium swallow [1, 2]. The lesions
are mostevidentwhen thecervicalesophagusisatmaximum
distension following the opening of the upper esophageal
sphincter. Characteristic findings are discussed in [1, 2]. The
most common pattern consists of two small indentations on
of the esophageal lumen (arrow) at the level of the thoracic inlet.
Figure 3: Endoscopic appearance of an annular inlet patch from
a different patient. The ectopic gastric mucosa is salmon-coloured
and velvety and is easily distinguished from the normal grey-white
esophageal epithelium. The raised border of the lesion corresponds
to the radiological findings of esophageal indentations. Image
reprinted with permission from Medscape.com, 2009. Available at:
the wall of the esophagus. Alternativelythe indentations may
be more prominent with an intervening bulge away from the
esophageallumen,as wasnoted inthe imagesofthecase pre-
sented here or there may be only a single indentation. Other
possible findings reflect the prominent border of the inlet
patch and include rim-like shadows and irregular outlines.
The diagnosis of inlet patch is confirmed via endos-
copy with biopsy. The lesion will be seen more often by
Radiology Research and Practice3
Figure 4: Histology of a portion of an inlet patch from a different
patient showing gastric mucosa adjacent to normal esophageal
mucosa with stratified squamous epithelium (top left). The gastric
mucosa shown here is antral-type as there are no oxyntic (acid-
secreting parietal cell) glands.
endoscopists whose custom is to withdraw the scope very
slowly through the upper sphincter in order to inspect the
arytenoids and vocal cords. At endoscopy, the lesion appears
salmon-coloured andvelvetyand iseasily distinguished from
the normal grey-white squamous epithelium of the esopha-
can be round or oval with a flat, slightly raised, or depressed
surface and may have heaped margins most often on the
lateral or posterior surfaces [3, 11]. The prominent margins
correlate with the radiological findings of indentations
and rim-like shadows on barium swallow. Histopathology
provides the definitive diagnosis by demonstrating gastric
mucosa adjacent to normal esophageal mucosa (Figure 4).
Histopathological studies have demonstrated that oxyntic
mucosa (gastric body-like with acid-secreting parietal cells)
gastric mucosa but cardiac, antral, and mixed types also
occur [3, 4, 7].
A treatment strategy based on symptoms and underlying
pathology is outlined in . There is no treatment required
for asymptomatic inlet patches. Affected individuals who
are symptomatic may find relief with the use of proton
pump inhibitors. Strictures and webs are treated with serial
dilatation [4, 6] but should include biopsy to rule out
malignancy . Ablation of inlet patches has been shown
to relieve globus  and has been used to successfully treat
inlet patch dysplasia although its routine use in this context
has not been determined .
As there was no evidence of mechanical obstruction,
the cause of our patient’s symptoms were thought to be
secondary to esophageal irritation from acid-secretion. He
responded well to treatment with a proton pump inhibitor.
 H. Takeji, J. Ueno, and H. Nishitani, “Ectopic gastric mucosa
in the upper esophagus: prevalence and radiologic findings,”
American Journal of Roentgenology, vol. 164, no. 4, pp. 901–
 J. Ueno, S. W. Davis, A. Tanakami et al., “Ectopic gastric
mucosa in the upper esophagus: detection and radiographic
findings,” Radiology, vol. 191, no. 3, pp. 751–753, 1994.
 D. W. Day et al., Morson and Dawson’s Gastrointestinal
Pathology, Blackwell, Malden, Mass, USA, 4th edition, 2003.
 N. Akbayir, C. Alkim, L. Erdem et al., “Heterotopic gastric
mucosa in the cervical esophagus (inlet patch): endoscopic
prevalence, histological and clinical characteristics,” Journal of
Gastroenterology and Hepatology, vol. 19, no. 8, pp. 891–896,
 G. Maconi,F. Pace, L. Vago, L. Carsana,S. Bargiggia, and G. B.
Porro, “Prevalence and clinical features of heterotopic gastric
mucosa in the upper oesophagus (inlet patch),” European
Journal of Gastroenterology and Hepatology, vol. 12, no. 7,
pp. 745–749, 2000.
 B. H. A. Von Rahden, H. J. Stein, K. Becker, D. Liebermann-
Meffert, and J. R. Siewert, “Heterotopic gastric mucosa of the
esophagus: literature-review and proposal of a clinicopatho-
logic classification,” American Journal of Gastroenterology,
vol. 99, no. 3, pp. 543–551, 2004.
 P. Tang, M. J.McKinley, M. Sporrer, and E. Kahn, “Inlet Patch:
prevalence, histologic type, and association with esophagitis,
Barrett esophagus, and antritis,” Archives of Pathology and
Laboratory Medicine, vol. 128, no. 4, pp. 444–447, 2004.
 B. Basseri, J. L. Conklin, R. B. Mertens, S. K. Lo, G. S. Bellack,
and O. A. Shaye, “Heterotopic gastric mucosa (inlet patch) in
a patient with laryngopharyngeal reflux (LPR) and laryngeal
carcinoma: a case report and review of literature,” Diseases of
the Esophagus, vol. 22, no. 4, pp. E1–E5, 2009.
 O. K. Poyrazoglu, I. H. Bahcecioglu, A. F. Dagli, H. Ataseven,
S. Celebi, and M. Yalniz, “Heterotropic gastric mucosa (inlet
ical and clinical characteristics,” International Journal of
Clinical Practice, vol. 63, no. 2, pp. 287–291, 2009.
 W. S. Silvers,J. S.Levine, J. A. Poole, E. Naar, andR. W.Weber,
“Inlet patch of gastric mucosa in upper esophagus causing
chronic cough and vocal cord dysfunction,” Annals of Allergy,
Asthma and Immunology, vol. 96, no. 1, pp. 112–115, 2006.
 E. JacobsandM. F. Dehou, “Heterotopic gastric mucosain the
upper esophagus:aprospective study of 33 cases andreview of
literature,” Endoscopy, vol. 29, no. 8, pp. 710–715, 1997.